I Would Never Do That!


June 2016

Authors note: All mishap reports mentioned here are courtesy of the www.ntsb.gov website.

A student pilot in a Cessna Skylane takes off for a 20-mile hop to another airport to take his Private Pilot Practical Test (checkride). There's a 900-foot ceiling and visibility is limited. A quarter mile from takeoff he loses control, crashes and burns.

A 17,000-hour ATP flying a Beechcraft A36 Bonanza lands with about eight gallons of fuel remaining. After dropping his passengers, he asks for "15 gallons a side" to be added, and the FBO correctly fills his order. With a total of under 40 gallons of fuel on board the ATP then launches on a three-hour trip back home--in an airplane that burns about 23 gallons per hour in climb and 17 gallons per hour in high-speed cruise. The airplane runs out of gas and crashes, killing the pilot.

Another Bonanza pilot nears his planned destination, where surface winds have increased far above what was forecast--now at 30 gusting to 40 knots, almost directly across the runway. The pilot loses directional control during landing and substantially damages the aircraft, although luckily he was not hurt.

Near the end of a long cross-country trip while descending visually after dark, a commercial pilot of a third Bonanza (I track Beech crashes closely, which is why so many of my examples involve this type) flies into a hillside less than 10 miles from his destination.

Reading these examples of real crash reports, some pilots might have the same reaction: "I would never do that!" It's easy for me to dismiss these as "stupid pilot tricks," in my opinion something no competent pilot would probably do. Yet with the exception of the student pilot in the Skylane, all the pilots had at one time demonstrated their ability to the FAA's satisfaction. The student pilot, by virtue of being endorsed to take his Practical Test that day, met the FAA standard at least in the opinion of his flight instructor. Yet, they all crashed. And it's pretty certain they each believed they could safely complete the accident flight.

Instead of dismissing these events (and the many, many others like them) as what I refer to as "stupid pilot tricks" or something you would probably never do, think of them as something you might accidentally do under the right (or wrong) circumstances. These types of crashes aren't really stupid; they are in my opinion evidence of two common pilot issues: failure to plan, and failure to monitor.

Failure to Plan 
In my opinion, three of the examples show a clear deficiency in preflight planning. The student Skylane pilot knew the weather conditions existed, but had been told (by the pilot examiner he was flying to meet) that the weather was expected to improve. The 17,000-hour ATP obviously did not take on enough fuel for the trip he was about to make. The last Bonanza pilot, descending in hilly terrain after dark, had not planned a terrain-avoiding route for his descent.

The student pilot was under self-imposed pressure to take his checkride because the Skylane had to go in for annual inspection in two days. The ATP told the FBO where he fueled he was "in a hurry" to get home, which may have negatively affected his flight planning. The last Bonanza pilot who descended into terrain was at the end of a six-hour transcontinental trip that was in itself the contraction of a two-day flight from Europe, and had been cruising at 12,500 feet without supplemental oxygen before beginning his descent. All four pilots exhibited the "go" mentality common to most pilots.

Failure to Monitor
All four pilots failed to monitor indications during their flight, and to alter the flight as necessary to suit the actual conditions. The student pilot should have seen before he ever took off that the expected improvement in ceiling and visibility had not yet occurred. The ATP did not continually update his fuel status while en route, computing expected fuel remaining at destination and comparing fuel gauge and other inflight indications to expectations. The second Bonanza pilot, who lost control trying to land in a 30 to 40 knot crosswind, had not updated his preflight weather briefing en route or listened to the AWOS at his destination. The Controlled Flight into Terrain pilot lost track of his precise position and his height in relation to obstacles beneath him, likely in part due to fatigue and the effects of hypoxia.

Although flight planning is emphasized in initial pilot training, it is not stressed in Flight Reviews and (in my experience with pilots) it is reduced to minimal, rule-of-thumb guesswork in day-to-day operations. Inflight monitoring is almost never taught in flight instruction, except perhaps in the minimal dual cross-country experience required by the FAA. The incredible capability of modern navigation and online flight plan filing make it more likely pilots will not study performance and aeronautical charts before a flight or crosscheck that planning against real conditions while en route, in my opinion, especially when distracted or stressed.

Pilots almost never intentionally attempt visual flight in instrument conditions, run out of gas, roll an airplane into a ball trying to exceed their crosswind capability or that of the aircraft, or fly the airplane under control into an obstacle. And in my opinion the resulting accident can be boiled down to failure to plan and failure to monitor, influenced by (usually self-imposed) stress. You can usually avoid performing "stupid pilot tricks" by approaching every flight with the same level of planning you demonstrated on your very first pilot certificate checkride, and then cross-checking that planning against the real world once you're in the air. Commit to planning and monitoring, and you will increase your chances of “never doing that”.

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Holder of an ATP certificate with instructor, CFII and MEI ratings and a Masters Degree in Aviation Safety, 2010 National FAA Safety Team Representative of the Year, 2015 Inductee into the NAFI Hall of Fame and 2008 FAA Central Region CFI of the Year, three-time Master CFI Thomas P. Turner has been Lead Instructor for Bonanza pilot training program at the Beechcraft factory; production test pilot for engine modifications; aviation insurance underwriter; corporate pilot and safety expert; Captain in the United States Air Force; and contract course developer for Embry-Riddle Aeronautical University. He now directs the education and safety arm of a 9000-member pilots’ organization. With over 4000 hours logged, including more than 2500 as an instructor, Tom writes, lectures and instructs extensively from his home at THE AIR CAPITAL--Wichita, Kansas. Subscribe to Tom’s free FLYING LESSONS Weekly e-newsletter at http://mastery-flight-training.com/

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